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4 views

Application Form

Uploaded by

Rohit Kumar
Copyright
© © All Rights Reserved
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30/06/2024, 14:48 Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 24-1008284981
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name BISHNU PRIYA SHAW
Date of Birth (DD/MM/YYYY) 29/07/2001
Validity Required NA
Place of Birth (Village/Town/City) NAIHATI
District NORTH 24 PARGANAS
State/UT WEST BENGAL
Region/Country INDIA
Gender FEMALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN OAOPS4128F
Voter Id IQN1118371
Employment Type NOT EMPLOYED
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark MOLE ON LEFT CHEEK
Aadhaar Number 527636436696
Family Details
Father's Name GAJANAND SHAW
Mother's Name BIJOY LAXMI SHAW
Legal Guardian's Name GAJANAND SHAW
Present Residential Address Details
165/1 RBC ROAD,POST-GARIFFA, NAIHATI, BARRACKPORE, WEST
Address
BENGAL
PIN 743165
Police Station NAIHATI PS
Mobile/Tel No. 9339058750
E-mail [email protected]
Permanent Residential Address
229/1 MITRA PADA ROAD, NAIHATI, BARRACKPORE, WEST BENGAL,
Address
INDIA
PIN 743165
Police Station NAIHATI PS
Mobile/Tel No. 9339058750
Emergency Contact Details
GAJANAND SHAW ADD:229/1 MITRA PADA
Name and Address
ROAD,NAIHATI,PINCODE:743165
Mobile/Tel No. 9339152638
E-mail [email protected]
Other Details
Enclosures
1.Transfer/School leaving/Matriculation Certificate issued by the school last attended/recognized educational board
2.Electors Photo Identity Card (EPIC)
Self Declaration
I owe allegiance to the sovereignty, unity & integrity of India, and have not voluntarily acquired citizenship or travel document of any
other country. I have not lost, surrendered or been deprived of the citizenship of India. I have not contravened any of the conditions
relating to the possession and use of an Indian passport.
I affirm that the information and particulars given by me in this form are true and correct. I further state that I am not suppressing any
material information in this regard. I further affirm that the enclosures and documentary proof submitted in support of my application for
an Indian passport are authentic and solely pertain to me and I am fully responsible for the accuracy of the same. I am liable to be

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30/06/2024, 14:48 Application Form
penalized or prosecuted if found otherwise. I am aware that under the Passports Act, 1967 it is a criminal offence to furnish any false
information or to suppress any material information with a view to obtaining passport or travel document.
I have read and understood the contents of the above and by submitting this form certify that all the information submitted by me in the
form is bonafide.
Place NAIHATI
Date 30/06/2024
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